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CITY OF JERSEY CITY

REQUEST FOR PROPOSALS:

EMPLOYEE MEDICAL SERVICES:

TO CONDUCT MEDICAL EXAMINATIONS OF CIVILIAN AND UNIFORMED EMPLOYEES

AND APPLICANTS FOR EMPLOYMENT SUBMISSION DEADLINE:

4:00 PM December 12, 2014

ADDRESS ALL PROPOSALS TO: Peter Folgado

Purchasing Agent 394 Central Avenue, 2nd Floor

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SECTION 1: GENERAL INFORMATION & SUMMARY 1.1 Organization Requesting Proposal

City of Jersey City - Department of Human Resources 280 Grove St.

Jersey City, NJ 07302

1.2 Contact Person

Peter Folgado Purchasing Agent

394 Central Avenue, 2nd Floor Jersey City, NJ 07307

(201) 547-5156 Peterf@jcnj.org

1.3 Procurement Process

This contract will be awarded as a professional services agreement using the “fair and open” process under the "New Jersey Local Unit Pay-to-Play" Law, N.J.S.A. 19:44A-20.4 et seq. Note that the successful Vendor is required to complete a Political Contribution Disclosure Form pursuant to City Ordinance 08-128 certifying that Vendor will make no reportable contributions during the term of the contract.

The City Council will vote to approve a resolution awarding a contract to the contractor for a sum not to exceed a specified amount.

1.4 Contract Form

If selected to provide services, it is agreed and understood that the successful Respondent shall be bound by the requirements and terms contained in this RFP with regard to services performed, payments, indemnification, insurance, termination, and applicable licensing provisions.

It is also agreed and understood that the acceptance of the final payment by Contractor shall be considered a release in full of all claims against the City arising out of, or by reason of, the work done and materials furnished under this Contract.

1.5 Informational Meeting

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1.6 Submission deadline

Proposals must be submitted to, and be received by the Department of Administration/Division of Purchasing mail or hand delivery, by 4:00 p.m. prevailing time on December 12, 2014. Proposals will not be accepted by facsimile transmission or e-mail.

1.7 Definitions

The following definitions shall apply to and are used in this Request for Proposal (RFP): "City" - refers to the City of Jersey City.

"RFP" - refers to this Request for Proposals, including any amendments thereof or supplements thereto.

"Respondent" or "Respondents" - refers to the interested persons and/or firm(s) that submit a Proposal.

“Consultant” or “Consultants” - refers to the interested persons and/or firm(s) that submit a Proposal.

“Vendor” or “Vendors” - refers to the interested persons and/or firm(s) that submit a Proposal. 1.8 Submission address

All proposals should be sent to: Peter Folgado

Purchasing Agent

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SECTION 2: INTRODUCTION AND GENERAL INFORMATION 2.1 Introduction and Purpose

The City is seeking proposals from a qualified doctor or medical staff of doctors for services as described herein.

2.2 Fair and Open Process

This contract will be awarded as a professional services agreement using the “fair and open” process under the "New Jersey Local Unit Pay-to-Play" Law, N.J.S.A. 19:44A-20.4 et seq. The City has structured a procurement process that seeks to obtain the desired services, while establishing a competitive environment to assure that each person and/or firm is provided an equal opportunity to submit a proposal in response to the RFP. Proposals will be evaluated in

accordance with the criteria set forth in Section 6 of this RFP, which will be applied in the same manner to each proposal received.

2.3 Evaluation Committee

Proposals will be reviewed and evaluated by the City's Business Administrator and/or his designee(s), and the Human Resources Director and/or her designee(s). The proposals will be reviewed to determine if the Respondent has met the professional, administrative, and subject areas described in this RFP.

2.4 Procurement Schedule

The steps involved in the process and the anticipated completion dates are set forth in the

Procurement Schedule below. The City reserves the right to, among other things, amend, modify or alter the Procurement Schedule upon notice to all potential Respondents.

Activity Date

1. Issuance of Request for Proposals November 19, 2014

2. Receipt of Proposals December 12, 2014

3. Completion of evaluation of Proposals December 29, 2014

4. Award of contract January 2015

2.5 Addenda or Amendments to RFP

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All Proposals shall be prepared with full consideration of the addenda issued prior to the Proposal submission date.

All communications concerning this RFP or the Proposal process shall be conducted through the City's Purchasing portal - BidSync.com. Responses to all questions will be forwarded as addenda to all prospective Vendors who have provided accurate and current contact information (mailing address, fax number, e-mail address), also via the BidSync portal.

No oral interpretation and or clarification of the meaning of the specifications for any goods and services will be made to any Vendor. Such request shall be through the City's Purchasing portal - BidSync.com. In order to be given consideration, a written request must be received at least seven (7) business days prior to the date fixed for the opening of the Proposal for goods and services.

Subsequent to issuance of this RFP, the City (through the issuance of addenda to all persons and/or firms that have received a copy of the RFP) may modify, supplement or amend the provisions of this Proposal specification in order to respond to inquiries received from prospective Vendors or as otherwise deemed necessary or appropriate by (and in the sole judgment of) the City.

2.6 Rights of the City

The City reserves, holds and may exercise, at its sole discretion, the following rights and options with regard to this RFP and the procurement process in accordance with the provisions of

applicable law:

• To conduct investigations of any or all of the Respondents, as the City deems necessary or convenient, to clarify the information provided as part of the Proposal and to request additional information to support the information included in any Proposal.

• To suspend or terminate the procurement process described in this RFP at any time (in its sole discretion.) If terminated, the City may determine to commence a new

procurement process or exercise any other rights provided under applicable law without any obligation to the Respondents.

2.7 Cost of Proposal Preparation

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2.8 Proposal evaluation

Proposals will be reviewed and evaluated by the City's Business Administrator and/or his designee(s), and the Human Resources Director and/or her designee(s), based on the specific criteria detailed in Section 6.

2.9 Written Proposal

Prospective Vendors must submit a written proposal in a format specified by the City. The required format is detailed in Section 3.

2.10 Oral presentation

There will be no oral presentation for this project. 2.11 Additional requirements

Consultant is required to comply with requirements of P.L. 1975, c. 127, the Law Against Discrimination and with N.J.A.C 17:27-1.1 et seq, the Affirmative Action Rules.

A party responding to this RFP must indicate what type of business organization it is e.g., corporation, partnership, sole proprietorship, or non-profit organization. If a party is a subsidiary or direct or indirect affiliate of any other organization , it must indicate in its proposal the name of the related organization and the relationship. If a party responding to this RFP is a corporation it shall list the names of those stockholders holding 10% or more of the outstanding stock.

Section 7 of this document describes general terms and conditions. Section 8 of this document contains required administrative forms which must accompany all proposals. Exclusion of any required form is grounds for rejection of proposals.

2.12 Disposition of RFP

Upon submission of a Proposal in response to this RFP, the Respondent acknowledges and consents to the following conditions relative to the submission and review and consideration of its Proposal:

• All Proposals shall become the property of the City and will not be returned.

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2.13 City of Jersey City “Pay to Play” Ordinance

On September 3, 2008, the City Council adopted Ordinance 08-128 which places stricter

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SECTION 3: WRITTEN PROPOSAL FORMAT

Proposals must address all information requested in this RFP. Proposals which in the judgment of the City fail to meet the requirements of the RFP or which are in any way conditional, incomplete, obscure, contain additions or deletions from requested information, or contain errors may be rejected. The Respondent shall, as part of its Proposal, provide the following information: 3.1 Qualifications

a. An executive summary (not to exceed two (2) pages) of the information contained in all the other parts of the Proposal.

b. An executed Letter of Qualification. (Sample letter in Section 8)

c. Name, address and telephone number of the Respondent submitting a Proposal pursuant to this RFP, and the name of the key contact person.

d. A description of the business organization (i.e., corporation, partnership, joint venture, etc.) of each Respondent, its ownership and its organizational structure.

(1) Provide the names and business addresses of all Principals of the Respondent submitting the Proposal. For purposes of this RFP, "Principals" means persons possessing an ownership interest in the Respondent. If the Respondent is a corporation, "Principals" shall include each investor who has any operational control over the Respondent, and every stockholder having an ownership interest of 10% or more in the firm. (Sample form in Section 8)

(2) If a Respondent is a partially owned or a fully-owned subsidiary of another firm, identify the parent company and describe the nature and extent of the parent’s approval rights over the activities of the Respondent submitting a Proposal. Describe the approval process.

(3) If the Respondent is a partnership or a joint venture or similar organization, provide comparable information as required in (2) above for each member of the

partnership, joint venture or similar organization.

(4) A statement that the Respondent has complied and will further comply with all applicable affirmative action /equal employment opportunity (or

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color, national origin, ancestry, age, sex, marital status, affectional or sexual orientation, disability or any other basis prohibited by the State of New Jersey and/or federal non discrimination laws.

(5) A statement that the Respondent will be in compliance with its Confidentiality Obligations with respect to its business activities, involving but not limited to use, collection, disclosure, recording, maintenance of medical data/documents and other medical-related information, in accord with the established local, state and federal laws on confidentiality requirements.

e. The number of years Respondent has been in practice under the present name. f. The number of years Respondent has been under the current management.

g. Any judgments within the last three (3) years in which Respondent has been adjudicated liable for professional malpractice. If yes, please explain.

h. Whether the Respondent is now or has been involved in any bankruptcy or re-organization proceedings in the last ten (10) years. If yes, please explain.

i. Confirm appropriate federal and state licenses to perform activities. j. An executed letter of intent. (Sample letter in Section 8)

3.2 Professional Information

a. Respondent shall submit a description of its overall experience in providing the type of services sought in the RFP. At a minimum, the following information on past experience should be included as appropriate to the RFP:

1. Description and scope of work by Respondent. 2. Name, address and contact information of references.

3. Explanation of perceived relevance of the experience to the RFP.

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c. Resumes of key employees.

d. Names and resumes of physicians who will be assigned to provide services to the City if the City awards a contract to Respondent.

e. List all immediate relatives of Principal(s) of Respondent who are City employees or elected officials of the City. For purposes of the above, "immediate relative" means a spouse, parent, stepparent, brother, sister, child, stepchild, direct-line aunt or uncle, grandparent, grandchild and in-laws.

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SECTION 4: SCOPE OF SERVICES

The Department of Human Resources is seeking a doctor or assigned medical staff of doctors to perform a variety of medical services for City employees.

4.1 General

The City is seeking a doctor or assigned medical staff of doctors to perform the following: - Pre-employment Physicals- civilians and members of uniformed services

- Hazardous Waste Material (HAZMAT) Physicals-members of uniformed services - OSHA Respirator Medical Evaluations- members of uniformed fire services - Bicycle Physical- members of uniformed police services

- Return to Work after Sickness Physicals - civilian and members uniformed services - Test Relative to Disability Pension Applications-civilian and members uniformed services - Certification of Illness in cases of illness in suspected abuse of sick/injury leave cases - Stand-alone procedures not part of an overall examination (see itemized list)

A brief description of the minimum required scope of services to be performed in the

aforementioned categories follows, along with the estimated number of each to be performed over the term of the contract (12 months):

4.2 Pre-employment Physicals 4.2.1 Civilian without EKG

a. For employees under age 45 b. Review of medical history

c. Clinical examination, including, but not limited to:

i. Musculoskeletal exam

ii. Respiratory evaluation

iii. Eye, ears, nose, throat exam, including visual acuity

iv. Cardiovascular evaluation

v. Gastrointestinal evaluation

vi. Urinalysis and drug screening

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4.2.2 Civilian with EKG

a. For employees over age 45 b. Review of medical history

c. Clinical examination, including, but not limited to:

i. Musculoskeletal exam

ii. Respiratory evaluation

iii. Eye, ears, nose, throat exam, including visual acuity

iv. Cardiovascular evaluation

v. Gastrointestinal evaluation

vi. Urinalysis and drug screening

d. EKG

Estimated number to be performed: 100

4.2.3 Public Health Nurse without EKG a. For employees under age 45 b. Review of medical history

c. Clinical examination, including, but not limited to:

i. Musculoskeletal exam

ii. Respiratory evaluation

iii. Eye, ears, nose, throat exam, including visual acuity

iv. Cardiovascular evaluation

v. Gastrointestinal evaluation

vi. Urinalysis and drug screening

d. Rubella

e. Mantoux

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4.2.4 Public Health Nurse with EKG a. For employees over age 45 b. Review of medical history

c. Clinical examination, including, but not limited to:

i. Musculoskeletal exam

ii. Respiratory evaluation

iii. Eye, ears, nose, throat exam, including visual acuity

iv. Cardiovascular evaluation

v. Gastrointestinal evaluation

vi. Urinalysis and drug screening

d. Rubella

e. Mantoux

f. EKG

Estimated number to be performed: 25

4.2.5 Public Safety (Police/Fire) a. Review medical history

b. Clinical examination

c. EKG

d. Chest X-Ray

e. SMA 6 (Liver & general if necessary) f. Blood Serum Triglycerides

g. Cardiac Stress Test

h. Two step PPD (Tuberculin Test) i. Pulmonary Function Test

j. Drug Screening Test- (Alcohol & Substance Abuse) k. Hepatitis Vaccination

l. Any other applicable medical test in complies with state federal EEO laws.

Estimated number to be performed: 100

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4.3 Hazardous Waste Material (Haz-Mat) Baseline Physical - Uniformed Police & Fire a. Physical Examination including history

b. Laboratory Studies (CBC & urinalysis)

c. Electrocardiogram

d. Pulmonary Function Test (with Pulmonologist interpretation) e. Audiometric Test (Industrial hearing test)

f. Chest X-Ray (written interpretation)

g. Any other applicable medical test in compliance with local, state and federal laws.

Estimated number to be performed: 100

4.4 OSHA Respirator Medical Evaluation-Uniformed Fire 4.4.1 OSHA Respirator Medical Evaluation-Uniformed Fire #1

a. Employee reading/interpretation of the Respirator Medical Evaluation Questionnaire

Estimated number to be performed: 25

4.4.2 OSHA Respirator Medical Evaluation-Uniformed Fire #2 a. Physical examination

Estimated number to be performed: 25

4.4.3 OSHA Respirator Medical Evaluation-Uniformed Fire #3 a. Pulmonary function test

Estimated number to be performed: 25

4.5 Bicycle Physical for Uniformed Police Officers a. Employee basic physical examination b. Pulmonary function test

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4.6 Return to Work Examination

Examine employee with respect to illness to ascertain employee’s fitness to return to work. May be contingent on employee receiving clearance to return from his/her personal physician.

Estimated number to be performed: 700

4.7 Certification of Illness (abuse sick/injury leave)

Examine employee and render an objective opinion in writing to the Human Resource Department as to legitimacy of an employee’s illness.

Estimated number to be performed: 185 4.8 Workability/Disability Pension Examination

Examine employee with respect to illness to ascertain employee’s fitness to return to work or Eligibility for disability pension.

Estimated number to be performed: 50

4.9 Stand-alone Procedures

Procedure Estimated number to be performed

EKG 50

X-Ray 25

Rubella 25

Mantoux 25

Hepatitis 125

Urine and Drug Screen 25

Flu Shots 165

Audiology 25

Random Drug Test 25

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4.10 Other Requirements

A. Availability for the assigned work are required as follows:

1. Pre-employment Physicals/Annual Physicals Civilian & Uniformed (Monday-Friday)- 8:30 AM -5:00PM and on Saturday from 8:30AM - 12:00PM).

If Saturday examinations are required, the City will notify the Vendor at least one week in advance.

2. Tests for Disability Pension Applications-(Monday-Friday) (8:30AM-5:00PM).

3. Return to Work after Sickness Physical- Monday-Sunday (24 hrs). 4. Certification of Illness- (Monday-Sunday) - (24hrs).

B. Assigned work to be performed within the following time frame:

1. Pre-employment Physical/Annual Physical-within two (2) working days of notice by phone or facsimile. In instances where the City seeks to schedule more than forty (40) physicals a week, five (5) working day’s notice will be given.

2. Return to Work-on date of notice by phone or facsimile with a maximum of two (2) hour lead time given by the Division of Human Resources.

3. Tests for Disability Pension Applications- within five (5) working days of call.

4. Certification of Illness- on date of notice by phone with a maximum of two (2) hour lead time given by the Human Resource Division.

C. Results of all assigned work will be given to the Division of Human Resources and/or in person designated by the Director of Human Resources via phone or facsimile on the following work day and in writing (copy of physicals, opinion, etc.) within four (4) working days.

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E. Billing will be done on a monthly basis itemized (pre-employment, return to work, annual etc.) and properly substantiated. Billing will be addressed to the City of Jersey City, Division of Human Resources, 280 Grove Street, Jersey City, N.J. 07302.

F. Vendor will provide the City with the names and resumes of any physician who will be examining employees under this contract. The Division of Human Resources may request that a physician no longer be assigned to examinations.

G. Free parking will be provided to City employees to be utilized while being examined, either in a facility owed by the Vendor or via a reimbursement/validation process. The parking lot will be in close proximity to the medical facility.

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SECTION 5: PROPOSAL SUBMISSION REQUIREMENTS

To be responsive, Proposals must provide all requested information, and must be in strict

conformance with the instructions set forth herein. Proposals and all related information must be bound, and signed and acknowledged by the Respondent.

5.1 Number of copies

One original copy with authorized signatures. 5.2 Proposal media

Proposals forwarded by facsimile or e-mail will not be accepted.

5.3 Proposal format

To facilitate a timely and comprehensive evaluation of all submitted proposals, it is essential that all Vendors adhere to the required response format. The City requires a standard format for all

proposals submitted to ensure that clear, concise and complete statements are available from each Vendor in response to requirements. The required format is detailed in Section 3.

The City is not under any obligation to search for clarification through additional or unformatted information submitted as a supplement to the formatted response. Where a proposal contains conflicting information, the City at its option may either request clarification or may consider the information unresponsive.

5.4 Proposal length

The exact presentation and layout format of proposals is up to the discretion of the Vendor. 5.5 Submission deadline

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SECTION 6: PROPOSAL EVALUATION

The City's objective in soliciting Proposals is to enable it to select a Respondent that will provide high quality and cost effective services to the citizens of Jersey City. The City will consider Proposals only from Respondents that, in the City's sole judgment, have demonstrated the capability and willingness to provide high quality services to the citizens of the City in the manner described in this RFP. 6.1 Evaluation methodology

Proposals will be reviewed and evaluated by the City's Business Administrator and/or his

designee(s), and the Human Resources Director and/or her designee(s) to select a Respondent that will provide high quality and cost effective services to the citizens of Jersey City. The City will consider Proposals only from Respondents that, in the City's sole judgment, have demonstrated the capability and willingness to provide high quality services to the citizens of the City in the manner described in this RFP.

Proposals will be evaluated by the City on the basis of which is the most advantageous, price and other factors considered. The evaluation will consider:

a. Experience and reputation in the field; and b. Price proposal; and

c. Availability to accommodate the required scheduling of the City; and d. Other factors demonstrated to be in the best interest of the City.

Each Proposal must satisfy the objectives and requirements detailed in this RFP.

The City will select the most advantageous Proposals based on all of the evaluation factors set forth in this RFP. The City will make the award(s) that is in the best interest of the City.

Each Proposal must satisfy the objectives and requirements detailed in this RFP. Successful

Respondents shall be determined by an evaluation of the total content of the Proposal submitted. The City reserves the right to:

a. Not select any of the Proposals;

b. Award a contract for the requested services at any time within the qualification period. Every Proposal should be valid through this time period.

The City shall not be obligated to explain the results of the evaluation process to any Respondent. 6.2 Contract award

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SECTION 7: GENERAL TERMS AND CONDITIONS

The following are general terms and conditions which may or may not be explained elsewhere in this RFP.

7.1 City’s right to reject

The City reserves the right to reject any or all proposals, if necessary, or to waive any informalities in the proposals, and, unless otherwise specified by the Respondent, to accept any item, items or services in the Proposal should it be deemed in the best interest of the City.

7.2 Original/Authorized signatures

Each proposal and all required forms must be signed in ink by a person authorized to do so. 7.3 Delivery of proposals

Proposals may be hand delivered or mailed consistent with the provisions of the legal notice to Respondents. In the case of mailed proposals, the City assumes no responsibility for proposals received after the designated date and time and will return late proposals unopened. Proposals will not be accepted by facsimile or e-mail.

7.4 Affirmative Action requirements

Consultants are required to comply with the provisions of N.J.S.A. 10:5-36 and N.J.A.C. 17:27 et seq. No firm may be issued a contract unless it complies with these affirmative action provisions. The Mandatory Equal Employment Opportunity/Affirmative Action Language for Goods, Professional Services and General Service Contracts, Exhibit A summarizes the full required regulatory text. Goods and Services (including professional services) consultants/contractors shall submit to the public agency, after notification of award but prior to execution of a goods and services contract, one of the following three documents:

a. A photo copy of a valid letter that the contractor is operating under an existing Federally approved or sanctioned affirmative action programs (good for one year from the date of the letter); or

b. A photocopy of a Certificate of Employee Information Report approval, issued in accordance with N.J.A.C. 17:27-4; or

c. A photocopy of an Employee Information Report (Form AA302) provided by the Division and distributed to the public agency to be completed by the contractor, in accordance with N.J.A.C 17:27-4.

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Department of Administration, Office of Equal Opportunity/Affirmative Action 280 Grove Street Room-103

Jersey City NJ 07302 Tel. #201-547- 4533 Fax# 201-547-5088

E-mail Address: abuanJ@jcnj.org

7.5 Business Registration Certificate

P.L. 2004, c. 57 (Chapter 57) amends and supplements the business registration provisions of N.J.S.A. 52:32-44 which impose certain requirements upon a business competing for or entering into a contract with a local contracting agency whose contracting activities are subject to the requirements of the Local Public Contracts Law (N.J.S.A. 40A:11-1 et seq).

Consultants are required to comply with the requirements of P.L. 2004, c. 57 (Chapter 57) which include submitting a copy of their Business Registration Certificate (BRC), issued by the NJ Department of the Treasury prior to a contract award.

For more information on obtaining a BRC, see Section 8. 7.6 Clarification of RFP

Should any difference arise as to the meaning or intent of this RFP, the City's Business Administrator’s decision shall be final and conclusive.

7.7 Indemnification

The Vendor, if awarded the contract, agrees to protect, defend and save harmless the City against damage for payment for the use of any patented material process, article or devise that may enter into the manufacture, construction or form a part of the work covered by either order or contract, and further agrees to indemnity and save harmless the City from suits or actions of every nature and description brought against it for, or on account of, any injuries or damages received or sustained by any party or parties by, or from, any of the acts of the contractor, its servants or agents.

7.8 Insurance requirements

The consultant shall maintain sufficient insurance to protect against all claims under Workmen's Compensation, General and Automobile Liability, and shall be subject to approval for adequacy of protection. Certificates of such insurance shall be provided the City when required. Insurance requirements are as follows:

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7.9 Termination

Should a dispute arise, and if, after a good faith effort at resolution, the dispute is not resolved, either party may terminate the contract by providing 30 days written notice to the other party,

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your proposal to facilitate Purchasing’s review.

CITY OF JERSEY CITY

PROJECT: Medical Services for Municipal Employees Respondent: ____________________________________________ Respondent’S CHECKLIST Item Respondent Initials Purchasing Review A. Non-Collusion Affidavit properly notarized

B. Public Disclosure Statement

C. Mandatory Affirmative Action Language D. Americans with Disabilities Act

E. MWBE Questionnaire

F. Affirmative Action Compliance Notice G. Employee Information Report

H. Business Registration Certificate I. Letter of Qualification

J. Letter of Intent K. Price Proposal

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I certify that I am ______________________________________________________________ of the firm of _________________________________________________________________ the bidder making the proposal for the above named project, and that I executed the said proposal with full authority so to do; that said bidder has not, directly or indirectly entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of free, competitive bidding in connection with the above named project; and that all statements contained in said proposal and in this affidavit are true and correct, and made with full

knowledge that the City of Jersey City relies upon the truth of the statements contained in said proposal and in the statements contained in this affidavit in awarding the contract for the said project.

I further warrant that no person or selling agency has been employed to solicit or secure such contract upon an agreement or understanding for a commission, percentage, brokerage or contingent fee, except bona fide employees or bona fide established commercial or selling agencies maintained by (N.J.S.A.52: 34-25)

(Signature of Respondent) _____________________________________________________

SUBSCRIBED AND SWORN TO

BEFORE ME THIS DAY ___________________________OF 20_________ (TYPE OR PRINT NAME OF AFFIANT UNDER SIGNATURE)

NOTARY PUBLIC OF

MY COMMISSION EXPIRES: 20 .

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accompanying the bid of said corporation or partnership there is submitted a public disclosure information statement. The statement shall set forth the names and addresses of all stockholders in the corporation or partnership who own ten percent (10%) or more of its stock of any class, or of all individual partners in the partnership who own a ten percent (10%) or greater interest therein.

STOCKHOLDERS:

Name Address % owned

SIGNATURE : _________________________________________________________________

TITLE:

________________________________________________________________ SUBSCRIBED AND SWORN TO

BEFORE ME THIS DAY ___________________________OF 20_________ (TYPE OR PRINT NAME OF AFFIANT UNDER SIGNATURE)

NOTARY PUBLIC OF

MY COMMISSION EXPIRES: 20 .

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[insert date]

Attn: Nancy A. Ramos Human Resources Director

Jersey City Department of Administration City Hall

280 Grove Street

Jersey City, New Jersey 07302

NancyR@jcnj.org

Dear Ms. Ramos:

The undersigned have reviewed the Proposal submitted in response to the Request for Proposals (RFP) issued by the City of Jersey City (City), dated November 16, 2011, in connection with the City’s need for [insert services].

We affirm that the contents of our Proposal (which Proposal is incorporated herein by reference) are accurate, factual and complete to the best of our knowledge and belief and that the Proposal is submitted in good faith upon express understanding that any false statement may result in the disqualification of (Name of Respondent).

(Respondent shall sign and complete the spaces provided below. If a joint venture, appropriate officers of each company shall sign.)

(Signature of Chief

(Signature of Chief

Executive Officer Financial Officer

(Typed Name and Title (Typed Name and Title

(Typed Name of Firm)* (Typed Name of Firm) *

Dated: Dated:

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[insert date] Attn: Nancy A. Ramos

Human Resources Director

Jersey City Department of Administration City Hall

280 Grove Street

Jersey City, New Jersey 07302

NancyR@jcnj.org

Dear Ms. Ramos:

The undersigned as Respondent, has (have) submitted the attached Proposal in response to a Request for Proposals (RFP), issued by the City of Jersey City (City), dated November 16, 2011, in connection with the City’s need for [insert services].

Name of Respondent HEREBY STATES

1. The Proposal contains accurate, factual and complete information.

2. Name of Respondent) agrees (agree) to participate in good faith in the procurement process as described in the RFQ and to adhere to the City’s procurement schedule.

3. Name of Respondent) acknowledges (acknowledge) that all costs incurred by it (them) in connection with the preparation and submission of the Proposal and any proposal prepared and submitted in response to the RFP, or any negotiation which results therefrom shall be borne exclusively by the Respondent.

4. Name of Respondent) hereby declares (declare) that the only persons participating in this Proposal as Principals are named herein and that no person other than those herein mentioned has any participation in this Proposal or in any contract to be entered into with respect thereto. Additional persons may subsequently be included as participating Principals, but only if acceptable to the City. (Name of Respondent) declares that this Proposal is made without connection with any other person, firm or parties who has submitted a Proposal, except as expressly set forth below and that it has been prepared and has been submitted in good faith and without collusion or fraud.

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(Respondent shall sign and complete the space provided below. If a joint venture, appropriate officers of each company shall sign.)

(Signature of Chief Executive Officer)

(Typed name and Title

Dated: (Typed name of Firm)

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A B C D E Examinations Estimated number Unit Cost Extended Cost (B x C) Agree/ Exception * Pre-employment-Civilian-No EKG 100 Pre-employment-Civilian-EKG 100 Pre-employment-Nurse-No EKG 25 Pre-employment-Nurse-No EKG 25 Pre-employment-Police/Fire 100 HAZMAT 100 OSHA Respirator #1 25 OSHA Respirator #2 25 OSHA Respirator #3 25 Bicycle Physical 25 Return to Work 700 Certification of Illness 185 Workability/Disability Pension 50 Stand-alone Procedures EKG 50 Chest X-Ray 25 Rubella 25 Mantoux 25 Hepatitis 125 Urine and Drug Screening 25

Flu shots 165

Audiology Test 25

Random Drug Testing 25 TOTAL COST

*In column E, Respondents must indicate whether they agree with the requirements as described in Section 4 or whether there are any exceptions. If there are exceptions, Respondents must describe them in detail on a separate exception sheet. Failure to describe exceptions may result in rejection of proposal.

Prepared by:

_______________________________________________ _______________________________

Print name Title

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PART I - Vendor Affirmation

The undersigned, being authorized and knowledgeable of the circumstances, does hereby certify that _________________________________(name of business entity) has not made any reportable contributions in the **one-year period preceding ________________________(date City Council awards contract) that would be deemed to be violations of Section One of the City of Jersey City’s Contractor Pay-to-Play Reform Ordinance 08-128 (attached hereto) and that would bar the award of this contract. I further certify that during the term of the contract ________________________ (name of business entity) will not make any reportable contributions in violation of Ordinance 08-128.

PART II - Signature and Attestation:

The undersigned is fully aware that if I have misrepresented in whole or part this affirmation and certification, I and/or the business entity, will be liable for any penalty permitted under law.

Name of Business Entity: Signed Title: Print Name Date: Subscribed and sworn before me this day of , 2 . (Affiant)

My Commission expires:

(Print name & title of affiant) (Corporate Seal)

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References

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